Variability in noncardiac surgical procedures in children with congenital heart disease

Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease

OBJECTIVES

As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time.

DESIGN

All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review.

SETTING

The study was conducted at a single urban academic tertiary pediatric hospital.

PARTICIPANTS

All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis.

INTERVENTIONS

Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function.

MEASUREMENTS AND MAIN RESULTS

A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%).

CONCLUSIONS

These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.

Patients With Congenital Heart Disease Undergoing Noncardiac Procedures at Hospitals With and Without a Cardiac Surgical Program

Background

The type and location of hospitals where patients with congenital heart disease (CHD) undergo noncardiac procedures have not been investigated. This study aimed to describe (1) the characteristics of these patients, (2) the distribution of procedures among hospitals with and without a cardiac surgical program and travel distances, (3) the characteristics determining the distribution, and (4) mortality rates.

Methods and Results

This is a retrospective cohort analysis of inpatient data from the Center for Healthcare Information and Analysis of the Commonwealth of Massachusetts, Texas Healthcare Information Collection, and Health Care Cost and Utilization Project State Inpatient Database. Children <18 years old with CHD who underwent noncardiac procedures were included. Distances were calculated using the Haversine formula. Logistic regression was performed to evaluate the odds of a procedure at a hospital with a cardiac program. There were 7435 encounters at 235 hospitals analyzed. Most procedures (87.8%) occurred at hospitals with a cardiac program. Patients at a hospital without a cardiac program had simple CHD (72.4%) with <1% with single ventricle disease. At hospitals with a cardiac program, 56.8% had simple CHD, 35.4% complex CHD, and 7.8% single ventricle disease. The median distance traveled was 25.2 miles (interquartile range, 10.3–73.8 miles) to a hospital with a cardiac program and 14.6 miles (interquartile range, 6.2–37.4 miles) to a hospital without a cardiac program (P<0.001). Single ventricle disease (adjusted odds ratio [aOR], 16.25 [95% CI, 7.22–36.61]) and ≥6 chronic conditions (aOR, 1.81 [95% CI, 1.57–2.09]) were associated with performance at a hospital with a cardiac program. Mortality rate was 3.8%.

Conclusions

Patients with CHD are more likely to travel to a hospital with a cardiac program for noncardiac procedures than to a hospital without; especially patients with single ventricle disease, other complex CHD, and with ≥6 chronic conditions.

The Role of Chronic Conditions in Outcomes following Noncardiac Surgery in Children with Congenital Heart Disease

OBJECTIVES

To compare outcomes in children with congenital heart disease (CHD) undergoing noncardiac surgery by presence of chronic conditions and identify associated risk factors.

STUDY DESIGN

Retrospective analysis of 14 031 children with CHD who underwent noncardiac surgery in the 2016 Healthcare Cost and Utilization Project Kid's Inpatient Database. Multivariable regression was used to assess patient and hospital factors associated with in-hospital mortality and length of stay (LOS).

RESULTS

Overall, 94% had at least 1 chronic condition. The in-hospital mortality rate was 5.6%. Neonates with CHD only had the highest mortality (15.6%); otherwise, children with CHD and at least 1 chronic condition had higher mortality than patients with CHD only (infant 3.93%, child 1.22%, adolescent 1.04% vs 2.34%, 0%, and 0%). Neonates (OR, 15.5; 95% CI, 7.1-34.1 vs adolescent), number of chronic conditions (OR, 1.34; 95% CI, 1.27-1.42), chronic conditions type (circulatory system; OR 2.46; 95% CI, 2.04-2.98), and low socioeconomic status (OR, 1.36; 95% CI, 1.05-1.77) were associated with increased mortality. The median LOS was 20 days (IQR, 5-66). Those with CHD and at least 1 chronic condition had a greater LOS (21 days; IQR, 5-68) than those with CHD only (9 days; IQR, 3-46). Neonates (adjusted coefficient, 44.3; 95% CI, 40.3-48.3 vs adolescent), Black race (adjusted coefficient, 4.78; 95% CI, 2.27-7.3), chronic condition indicator number (adjusted coefficient, 5.17; 95% CI, 4.56-5.78), and subtype (adjusted coefficient, 23.6; 95% CI, 20.4-26.7) were associated with a prolonged LOS.

CONCLUSIONS

Most children with CHD who undergo noncardiac surgery have at least 1 chronic condition. Age, chronic conditions type and number, low socioeconomic status, and Black race impart increased risks of in-hospital mortality and prolonged LOS. Further research is needed to evaluate the impact of specific chronic conditions and determine barriers to equitable care.

The Practice of Pediatric Cardiac Anesthesiology in the United States

BACKGROUND

With advances in surgical and catheter-based interventions and technologies in patients with congenital heart disease (CHD), the practice of pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct subspecialty over the past 80 years. To date, there has not been an analysis of the distribution of pediatric cardiac anesthesiologists relative to cardiac and noncardiac procedures in the pediatric population. The primary aim is to report the results of a survey and its subsequent analysis to describe the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures that include surgical interventions, cardiac catheterization procedures, imaging studies (echocardiography, magnetic resonance, computed tomography, positron emission tomography), and noncardiac procedures.

METHODS

A survey developed in Research Electronic Data Capture (REDcap) was sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States. Data regarding cardiac surgical patients and procedures were collected from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHD).

RESULTS

This analysis reveals that only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) have gained experience during their clinical practice. Other providers have pursued different training pathways such as adult cardiac anesthesiology or pediatric critical care. Based on this survey, pediatric cardiac anesthesiologists devote 35% (interquartile range [IQR], 20%-50%) of clinical time to the care of patients in the cardiac operating room, 25% (20%-35%) of time to the care of patients in the cardiac catheterization laboratory, 10% (5%-10%) to patient care in imaging locations, and 15% covering general pediatric, adult, or cardiac patients undergoing noncardiac procedures. Attempts to actively recruit pediatric cardiac anesthesiologists were reported by 49.2% (29 of 59) of the institutions surveyed. Impending retirement of staff was anticipated in 17% (10 of 59) of the institutions, while loss of staff to relocation was anticipated in 3.4% (2 of 59) of institutions. Thirty-seven percent of institutions reported that they anticipated no immediate changes in current staffing levels.

CONCLUSIONS

The majority of currently practicing pediatric cardiac anesthesiologists have not completed a fellowship training in the subspecialty. There is, and will continue to be, a need for subspecialty training to meet increasing demand for services especially with increase survival of this patient population and to replace retiring members of the workforce.

Enteral access and fundoplication in children with congenital heart disease

Congenital heart disease (CHD) is the most frequently occurring congenital disorder and affects approximately 1% of live births.^1,2 Advancements in supportive technology and surgical techniques have allowed many of these children to live into adulthood with reductions in morbidity and mortality.^3,4 During infancy, many children with CHD are plagued with co-existing structural anomalies and/or feeding disorders that make adequate oral intake impossible.⁵ Pediatric surgeons are frequently consulted for enteral access and/or fundoplication to ensure proper growth and development while preventing potential hemodynamic instability caused by significant reflux events. The successful execution of a non-cardiac surgery in a child with significant cardiac risk factors requires the coordination and expertise of multiple providers with a deep understanding of pediatric CHD physiology to ensure a safe outcome. We review critical pre-operative workup, technical operative aspects, and anesthesia considerations in this unique patient population.

Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery?

With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.

Trends in mortality rate in patients with congenital heart disease undergoing noncardiac surgical procedures at children's hospitals

Advances made in pediatric cardiology, cardiac surgery and critical care have significantly improved the survival rate of patients with congenital heart disease (CHD) leading to an increase in children with CHD presenting for noncardiac surgical procedures. This study aims (1) to describe the trend and perioperative mortality rates in patients with CHD undergoing noncardiac surgical procedures at children's hospitals over the past 5 years and (2) to describe the patient characteristics and the most common type of surgical procedures. The Pediatric Health Information System (PHIS) is an administrative database that contains inpatient, observation, and outpatient surgical data from 52 freestanding children's hospitals. Thirty-nine of the 52 hospitals submitted data on all types of patient encounters for the duration of the study from 2015 to 2019. The total numbers of non-cardiac surgical encounters among patients with history of a CHD diagnosis significantly increased each year from 38,272 in 2015 to 45,993 in 2019 (P < 0.001). Despite the increase in case numbers, there has been a significant decline in mortality rates to the most recent incidence of 1.06% in 2019. Careful patient selection and medical optimization of patients aligned with specific expertise at dedicated children's hospitals may lead to improvement in mortality rate. Future studies comparing the outcomes of patients with cardiac disease based on hospital type and volume as well as type of providers may help determine the future of care including potential need for regionalization of noncardiac care for this vulnerable patient population.

Anaesthesia risks for non-cardiac procedures in cardiac patients

The number of patients with complex congenital heart disease (CHD) presenting for non-cardiac procedures is steadily increasing and more and more anaesthesiologists will be asked to participate in their care. This can be a very challenging task and will require adequate planning and preparation, but also some basic scientific inquiries.

Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk

The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.

Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease

Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.

Noncardiac surgery in the congenital heart patient

More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.

Cardiac Risk Factors and Complications After Spinal Fusion for Idiopathic Scoliosis in Children

BACKGROUND

Cardiac risk factors pose challenges in pediatric posterior spinal fusion (PSF). Differences in risk according to etiology of cardiac disease are unclear. We investigated outcomes of PSF according to presence of congenital heart defect compared to cardiomyopathy.

METHODS

Elective PSF for idiopathic scoliosis in patients aged 0-18 y was identified in the 2012-2015 National Surgical Quality Improvement Program-Pediatric. Cardiac risk factors were classified as: no cardiac risk factors or minor cardiac risk factors without congenital heart defect; minor cardiac risk factors because of congenital heart defect; major cardiac risk factors because of congenital heart defect; major cardiac risk factors because of cardiomyopathy. Multivariable logistic regression compared surgical site infection, wound dehiscence, hospital length of stay ≥30 d, and unplanned readmission across these categories.

RESULTS

The analysis included 5395 girls and 1691 boys, aged 14 ± 2 y. Among these, 140 patients had minor cardiac risk factors because of congenital heart defect, 144 had major cardiac risk factors because of congenital heart defect, and 20 had major cardiac risk factors because of cardiomyopathy. Rates of any complication were significantly higher among patients with cardiomyopathy (40%) compared to patients with major cardiac risk factors because of congenital heart defect (10%), minor cardiac risk factors because of congenital heart defect, or other minor or no cardiac risk factors (5%; chi-square P < 0.001). In multivariable analysis of 6829 patients, cardiomyopathy predicted greater odds of unplanned readmission compared to no or minor cardiac risk factors (OR = 5.9; 95% CI: 1.8, 19.7; P = 0.004) and compared to major cardiac risk factors because of congenital heart defect (OR = 4.5; 95% CI: 1.1, 17.6; P = 0.032).

CONCLUSIONS

Cardiomyopathy is a rare but significant risk factor for complications after pediatric PSF, whereas congenital heart defects did not independently contribute to risk of complications after this procedure.

Outcomes of laparoscopic and open surgery in children with and without congenital heart disease

BACKGROUND

Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD.

METHODS

We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children <18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay.

RESULTS

Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children.

CONCLUSIONS

Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD.

LEVEL-OF-EVIDENCE

Level III: Treatment Study.

Induction techniques for pediatric patients with congenital heart disease undergoing noncardiac procedures are influenced by cardiac functional status and residual lesion burden

STUDY OBJECTIVE

Appropriate agent selection in patients with congenital heart disease (CHD) undergoing cardiac surgery and catheterization have been extensively reviewed in the literature. To date, there has not been an analysis of induction drug choices made in a large group of CHD patients undergoing non-cardiac procedures and intraoperative events. The primary objective was to characterize induction agent selection in CHD patients undergoing non-cardiac procedures and examine its association with intraoperative events.

DESIGN

Retrospective chart review analysis.

SETTING

A single center study.

PATIENTS

Children with CHD who underwent non-cardiac procedures.

INTERVENTION/MEASUREMENT

Using the electronic preoperative anesthesia evaluation form we identified 2966 cases performed under general anesthesia. We examined the association between patient characteristics (ASA PS and CHD severity) and induction drugs using multinominal logistic regression test. We also examined the association of induction drugs with intraoperative adverse events using Fisher exact test.

MAIN RESULTS

Inhalational and intravenous inductions were conducted in 35.7% and 64.3% of general anesthesia cases, respectively. Sevoflurane was the main inhalation induction drug. Propofol was used as the induction agent in 54.3% of cases, while etomidate, midazolam/fentanyl, and ketamine were used as the induction agent in 18.3% 16.6%, and 10.1% of cases, respectively. ASA PS and CHD severity predicted induction drugs better than single ventricle status or ventricular function. Intraoperative inotrope use was seen more frequently in cases induced by ketamine, etomidate or opioids over sevoflurane or propofol.

CONCLUSIONS

Patients with higher ASA classes and CHD of more severity tend to be induced more with etomidate, ketamine or opioids over sevoflurane or propofol. Use of etomidate, ketamine or opioids was more associated with inotrope use, but there was not significant difference in respiratory events among different induction agents. Causative association needs to be examined in the future.

The Utility of Simulation in the Management of Patients With Congenital Heart Disease: Past, Present, and Future

Significant advancements have been made in the diagnosis and management of congenital heart disease (CHD). As a result, a higher percentage of these patients are surviving to adulthood. Despite this improvement in management, these patients remain at higher risk of morbidity and mortality, particularly in the perioperative setting. One new area of interest in these patients is the implementation of simulation-based medical education. Simulation has demonstrated various benefits across high-acuity scenarios encountered in the hospital. In CHD, simulation has been used in the training of pediatrics residents, assessment of intraoperative complications, echocardiography, and anatomic modeling with 3-dimensional printing. Here, we describe the current state of simulation in CHD, its role in training care providers for the management of this population, and future directions of CHD simulation.

The Care of Children With Congenital Heart Disease in Their Primary Medical Home

Congenital heart disease (CHD) is the most common birth anomaly. With advances in repair and palliation of these complex lesions, more and more patients are surviving and are discharged from the hospital to return to their families. Patients with CHD have complex health care needs that often must be provided for or coordinated for by the primary care provider (PCP) and medical home. This policy statement aims to provide the PCP with general guidelines for the care of the child with congenital heart defects and outlines anticipated problems, serving as a repository of current knowledge in a practical, readily accessible format. A timeline approach is used, emphasizing the role of the PCP and medical home in the management of patients with CHD in their various life stages.

Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease

OBJECTIVES

To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD).

STUDY DESIGN

Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD.

RESULTS

Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13).

CONCLUSIONS

Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.

Overall Hospital Cost Estimates in Children with Congenital Heart Disease: Analysis of the 2012 Kid's Inpatient Database

This study sought to determine overall hospital cost in children with congenital heart disease (CHD) and to compare cost associated with cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical admissions. The 2012 Healthcare Cost and Utilization Project Kid's Inpatient Database was used to evaluate hospital cost in neonates and children with CHD undergoing cardiac surgery, cardiac catheterization, non-cardiac surgical procedures, and medical treatments. Multivariable logistic regression was applied to determine independent predictors for increased hospital cost. In 2012, total hospital cost was 28,900 M$, while hospital cost in children with CHD represented 23% of this total and accounted for only 4.4% of hospital discharges. The median cost was $51,302 ($32,088-$100,058) in children who underwent cardiac surgery, $21,920 ($13,068-$51,609) in children who underwent cardiac catheterization, $4134 ($1771-$10,253) in children who underwent non-cardiac surgery, and $23,062 ($5529-$71,887) in children admitted for medical treatments. Independent predictors for increased cost were hospital bed size <400 beds (P < 0.001), more than four procedures performed during the same hospitalization (P = 0.001), use of ECMO (P < 0.001), length of hospital stay exceeding 14 days (P < 0.001), cardiac failure (P < 0.001), sepsis (P < 0.001), acute kidney injury (P < 0.001), and neurologic (P < 0.001) and thromboembolic complications (P < 0.001). Hospital cost in children with CHD represented 23% of global cost while accounting for only 4.4% of discharges. This study identified factors associated with increased cost of cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical management in children with CHD.